Citation Nr: 1323455 Decision Date: 07/23/13 Archive Date: 08/01/13 DOCKET NO. 05-00 804 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: Kenneth M. Carpenter, Attorney at Law ATTORNEY FOR THE BOARD A. Hinton, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from February 1966 to April 1970. This matter is before Board of Veterans' Appeals (Board) on appeal of a September 2003 rating decision of a Department of Veterans Affairs (VA) Regional Offices (RO). In April 2008 and in January 2012, the Board remanded the claim. In accordance with 38 U.S.C.A. § 7109 and 38 C.F.R. § 20.901, in July 2013, the Board obtained a medical expert opinion from the Veterans Health Administration (VHA). As the VHA expert's opinion is favorable to claim, the Board is proceeding with a decision as there is no prejudice to the Veteran. FINDING OF FACT Hypertension is proximately due to service-connected posttraumatic stress disorder. CONCLUSION OF LAW The criteria for service connection for hypertension have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.310 (2012). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. As the claim is granted, further discussion of VCAA compliance is not necessary. REASONS AND BASES FOR FINDING AND CONCLUSION Principles and Theories of Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active military service or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active military service. 38 U.S.C.A. § 1110 (wartime service). Generally, to establish entitlement to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so called "nexus" requirement. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as cardiovascular-renal disease to include hypertension, are presumed to have been incurred in service, if the condition becomes manifest to a degree of ten percent or more within a one-year presumptive period, following service. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted on a secondary basis for a disability that is proximately due to or is aggravated by a service-connected disability. 38 C.F.R. § 3.310(a). Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competency is a question of fact, which is to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Facts and Analysis The Veteran served on active duty from April 1967 to April 1970, including service in Vietnam. The service treatment records contain no complaint, finding, or history of elevated blood pressure or hypertension. After service, private medical records document hypertension in November 1999 and hypertension was diagnosed on VA examination in August 2003. Private medical records document elevated blood glucose in December 2002 and non-insulin dependent diabetes was diagnosed on VA examination in August 2003. Posttraumatic stress disorder was diagnosed on VA examination in July 2003. In November 2009 on VA examination, the VA examiner expressed the opinion that hypertension was not likely etiologically related to the Veteran's combat experiences (PTSD) and hypertension did not increased in severity beyond its natural progression by diabetes mellitus or by other service-connected disabilities. The VA examiner explained that hypertension was not diagnosed until 2000 and that there was no reference to high blood pressure in service. In July 2013, the Board obtained a medical expert opinion from the Veterans Health Administration. The VHA expert noted the following material facts regarding the Veteran's case with respect to a relationship between hypertension and service-connected diabetes: the Veteran served in Vietnam between 1967 and 1970; there was no diagnosis of hypertension during this time; hypertension was diagnosed in August 2003; currently blood pressure is well controlled on one blood pressure agent; the Veteran was initially found to have an elevated blood sugar in 2002, and diagnosed by VA with diabetes in 2003; diabetes is well controlled on oral medications; the Veteran does not have diabetic retinopathy, and has normal kidney function. Based on a review of the record, the VHA medical expert, the Chief of Nephrology at a VA medical center expressed the opinion that it was less likely than not hypertension was caused by or aggravated by diabetes. The VHA expert also noted the following material facts regarding the Veteran's case, with respect to a relationship between hypertension and service-connected PTSD: based on review of the literature it appears that PTSD is a strong risk factor for both incident hypertension, and a higher mean blood pressure; a study suggested that military service members deployed with multiple combat exposures were 1.33 times more likely to have hypertension, compared to those who did not see combat while deployed; similarly, another study suggested that patients with PTSD have a higher systolic and diastolic blood pressure than control patients (systolic blood pressure of 133.8 versus 122.3 mmHg); and another study that patients with PTSD were 1.62 times more likely to have hypertension, compared to those without PTSD. On the basis of a review of the literature, the VHA expert expressed the opinion that it is more likely than not (a probability of more than 50 percent), that hypertension was either caused by or aggravated by PTSD. Service connection is in effect for PTSD, rated 70 percent, and for diabetes mellitus, rated 20 percent. Analysis It is not argued or shown that hypertension is directly related to service on the theories that hypertension had onset in service, that hypertension as a chronic was manifested within the one-year presumptive period, or that hypertension is related to service by chronicity and continuity of symptomatology. The Veteran does assert that hypertension was caused by or aggravated by service-connected diabetes mellitus, type 2, or service-connected posttraumatic stress disorder. The probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. The guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts, and whether the expert applied valid medical analysis to the significant facts of the case in order to reach the conclusion rendered in the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-3 (2008). The medical evidence against the claim is the opinion of the VA examiner in November 2009 that hypertension was not likely etiologically related to the Veteran's combat experiences (PTSD) and hypertension did not increased in severity beyond its natural progression by diabetes mellitus or by other service-connected disabilities. The VA examiner explained that hypertension was not diagnosed until 2000 and that there was no reference to high blood pressure in service. The medical evidence in favor of the claim is the opinion of the VHA expert. Although the VHA expert expressed the opinion that it was less likely than not hypertension was caused by or aggravated by diabetes, the VHA expert expressed the opinion that it was more likely than not (a probability of more than 50 percent), that hypertension was either caused by or aggravated by PTSD. The Board finds that the opinion of the VA examiner is outweighed by the opinion of the VHA expert, as the opinion of the VHA expert was based on the significant facts of the case and a review of the medical literature. And the VHA expert provided a persuasive rationale for the conclusion reached in the opinion. For this reason, the Board finds that the favorable opinion of the VHA expert is persuasive and outweighs the unfavorable medical opinion, and service connection for hypertension under 38 C.F.R. § 3.310 is warranted. ORDER Service connection for hypertension is granted. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs